Job Summary:
The Revenue Cycle & Quality Assurance Specialist oversees billing operations, documentation quality, compliance activities, and provider enrollment support across three outpatient mental health clinics. This role ensures the accuracy, integrity, and compliance of clinical documentation, billing processes, and provider enrollment records while supporting quality improvement initiatives.
Working closely with clinical, operational, and finance leadership, the Revenue Cycle and Quality Assurance Specialist monitors billing performance, identifies documentation issues, improves revenue cycle outcomes, supports provider enrollment activities, and ensures compliance with federal and California regulatory requirements, payer requirements, and organizational policies.
Essential Functions
Billing, Documentation, and Compliance
- Oversee billing operations and review claims, billing data, and clinical documentation to ensure accurate, compliant, and timely reimbursement.
- Resolve claim denials, rejections, underpayments, and billing discrepancies while reconciling billing activity with EHR and clinical records.
- Conduct chart audits and documentation reviews to verify services billed are supported by clinical records and meet payer, regulatory, accreditation, and organizational requirements.
- Identify documentation, billing, and compliance deficiencies; recommend corrective actions, training, and workflow improvements.
- Monitor compliance with internal policies and external regulatory standards and support audit, accreditation, and review activities.
Quality Assurance, Reporting, and Performance Improvement
- Maintain quality assurance tracking systems, corrective action plans, and related records.
- Generate, analyze, and interpret data from EHR, billing, and practice management systems to monitor key performance indicators, trends, risks, and opportunities for improvement.
- Prepare reports and support data collection for leadership, audits, compliance activities, and performance improvement initiatives.
- Partner with clinic leadership and finance staff to improve documentation quality, billing accuracy, compliance, and overall revenue cycle performance.
Collaboration, Training, and Operational Support
- Serve as a resource for billing, documentation, compliance, and quality assurance questions.
- Provide training and coaching on documentation standards, billing requirements, compliance expectations, and quality assurance processes.
- Collaborate with clinic leadership to promote consistency, reduce errors, and implement process improvements across locations.
- Provide administrative and project support for operational initiatives, policy updates, and organizational priorities.
- Manage provider credentialing and payer enrollment activities, including credentialing file maintenance, licensure and certification tracking, CAQH and NPI updates, and enrollment, revalidation, and participation with Medicare, Medi-Cal, and commercial health plans.
- Perform other duties as assigned.
Minimum Qualifications
- Associate's or Bachelor's degree in Healthcare Administration, Business Administration, Public Health, Accounting, Finance, or a related field preferred or 5 years experience.
- Minimum of three (3) years of experience in healthcare billing, revenue cycle management, quality assurance, compliance, or healthcare operations.
- Experience supporting outpatient behavioral health, mental health, healthcare, or medical practice settings strongly preferred.
- Working knowledge of commercial insurance, Medicare, managed care, and behavioral health billing practices.
- Experience conducting documentation reviews, chart audits, or compliance monitoring activities preferred.
- Strong understanding of healthcare documentation standards and revenue cycle processes.
- Advanced proficiency in Microsoft Excel, including pivot tables, formulas, and reporting functions.
- Experience working with Electronic Health Records (EHR) and practice management systems.
- Strong analytical, organizational, and problem-solving skills.
- Excellent written and verbal communication skills.
- Ability to manage multiple priorities across several clinic locations.
- Successful completion of a criminal background check.
Preferred Qualifications
- Certified Professional Biller (CPB), Certified Revenue Cycle Representative (CRCR), Certified Professional Coder (CPC), Certified Provider Credentialing Specialist (CPCS), Certified Professional Medical Services Management (CPMSM), or similar certification preferred.
- Experience supporting multi-site healthcare or behavioral health organizations.
- Experience with accreditation standards, compliance monitoring, or quality improvement programs.
Environmental Factors and Physical Requirements
- Work is performed primarily in a climate-controlled office environment.
- Frequent use of computers and electronic systems for extended periods.
- May require travel between clinic locations as needed.
- Occasional evening or weekend work may be required.
- Ability to occasionally lift and/or move up to 25 pounds.